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Waste Tire SL. fey & Inspection Report Inspection Repo!t Number <br /> State of California <br /> CalRecycle 11 - 1196596 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 _ d � Inspection Type(Fill one) <br /> Site Suffix: b (0 `� Or-Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sam J v n O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By r Inspector <br /> PhysicalAddress <br /> -301 (7 <br /> ­"IoGe__VV�A� <br /> Inspection Date 2 / 7 / I <br /> Time In Time Out <br /> Business Rep Title C� C, O AMO AM <br /> ��V1 `1� `� W'�A � � J ✓ ® PM Z Z S ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Z ® (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' V Active O Passenger Generator 0 Outdoor <br /> O Q Closed O Altered <br /> GpS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) c_ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder S Other fv`b VOt G L` '_ t <br /> Part B- Inspection of Waste.Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q 1Other:§ <br /> z <br /> \ _ <br /> Comments C� 6A "� $ r1.01 <br /> Gil <br /> Inspection Form Included: QA"LxO m/lv <br /> Comments Included: <br /> Busi p's ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X IIEIXIAIMIPILIEI 1112 3 62081 <br /> . White Copy:CalRecycle . Yellow Copy:Operator Pink Copy:LEA ® 0 <br />